Call Your Doctor

A woman underwent outpatient surgery for a nerve problem in her forearm. Upon leaving the ambulatory surgery center, she was given an instruction sheet advising her to call her doctor if she had a high fever, bleeding, or excessive pain.

The next day, she was in agonizing pain. The pain pills did not help. She called her doctor who told her to remove the dressings. She did so, but the pain continued unabated.

She called her doctor again, frantically complaining of pain. According to the record, she was terribly distressed, clutching her hand, rocking back and forth with no relief. He reassured things were fine and he would see her in his office the day after tomorrow.

Hours went by. The intense pain gradually receded.

In the following weeks, she noted an inability to move portions of her hand and fingers. This did not improve with time. During appointments with her doctor, he seemed unconcerned about her complaints.

Finally, she saw another surgeon for a second opinion and was advised that she likely had suffered a compartment syndrome. A Volkman’s contracture resulted from the ischemia, the muscles reduced to rigid scar tissue. She underwent another operation consisting of selective tendon transfers to restore function.

She regained fairly good function from the second procedure.

In our HUMBLE OPINION,

Doctor Witherspoon Says:

Not again! Another missed compartment syndrome. Another miserable lesson learned long ago that we have to relearn all over again.

Guess I’ll run through the basics. A compartment syndrome can occur in any extremity, most commonly the calf. Anything that causes excessive swelling can bring it on, in this case a prolonged dissection with a lot of tissue manipulation. After closure, pressure built up within the swollen forearm such that blood perfusion through the muscle capillary bed ceased.

Ischemia, muscle death, and scar tissue contraction with loss of function resulted, the Volkman’s ischemic contracture. It can be devastating.

Some injuries are famous for causing a compartment syndrome. Comminuted tibia fractures, tibial plateau fractures, vascular or crush injuries; anything that causes swelling or fluid accumulation can bring it on.

Clinical signs include excessive pain, worsened with passive motion. The limb will be swollen with a woody firmness. Later comes sensory loss – 2-point discrimination and vibratory sense go first. Late into the condition you might lose the pulse and, if so, you now have a limb-threatening situation.

The classic test is measurement of the compartment pressure. 30 mmHg or above is the most common recommendation. There are other formulas I won’t get into.

A soon as you make the diagnosis, get to the OR and decompress the compartments. Cut the fascia, a single slit the full length of each compartment. In this case, just open the incision and do dressing changes until the swelling goes down and you can close it.

Timing is crucial. After six hours some degree of necrosis will likely occur. Twelve hours untreated and the compartments are done for. You end up with a Volkman’s. It’s a true medical emergency so as soon as you make the diagnosis, bump the elective stuff and get to the OR.

That’s the textbook version. If you talk to the old guys who’ve been around and dealt with this before, (humbly suggest yours truly qualifies in that regard) you’ll get the voice of experience.

The most prominent characteristic of this condition is pain. Oxygen starvation to muscle tissue is painful and this is one of the most painful conditions in all of clinical medicine. Ranks right up there with an aortic dissection or ruptured middle cerebral artery aneurysm.

These people are absolutely frantic. I’ve not seen morphine, demeral, dilaudid, or any of the usual narcotics give satisfactory relief. They won’t rest easy until you break out the propofal.

Next, if you passively stretch the oxygen-starved muscles, the pain will skyrocket. Gently move a toe or finger up or down. The result may be ear splitting. Any attempt of active motion will be even worse.

The limb is wooden-stiff, almost rock solid. This will be in marked contrast to the opposite limb.

Rigid, swollen limb, frantic pain dramatically increased with passive stretch: that’s enough for me, folks. When I see that picture, I don’t need a pressure measurement: I’ll take ‘em straight to the OR.

If you’re unsure, if the picture’s equivocal, the patient semi-conscious etc., then you’ll need to measure the compartments to see where you are. But an outright raging compartment syndrome is an unforgettable presentation you need to see only once to have it burned in your memory.

Now this case. She had extremity surgery with considerable dissection. Upon departure from the ambulatory surgery center she was given an instruction sheet that said, among other things, to call her doctor if she had excessive pain.

She called twice, complaining of severe pain and was ignored.

That’s what singes my whiskers. Excessive pain, what we call “pain out of proportion” is a classic red flag that should get the surgeon’s radar up. If it seems mild, you might suggest ice, elevation, or remove the dressings as was advised on the first call. But if the patient sounds frantic, like this one, you need to get moving. I don’t have a problem with how he responded to the first call, but that second call should have been a call to action. Get her to the ER.

“Pain out of proportion.” Compartment syndrome. Infection. Hidden abscess. Nerve compression. Fixation failure. Anastomosis breakdown. Expanding hematoma. The list of potential complications heralded by “pain out of proportion” is extensive and every one of ‘em can cause serious problems if neglected.

There’s no yardstick to precisely measure a patient’s discomfiture. But, through experience, the good doctor will learn the typical, anticipated recovery pattern for his procedures and will quickly become concerned when a patient moves outside the expected recovery profile. He’ll get his radar up, and start looking for something amiss.

“Pain out of proportion.” Like good art, the good doctor knows it when he sees it and acts accordingly.

Finally, our patients should expect to be made reasonably comfortable after surgery. You just don’t leave a patient hanging out in agony like that. Not only do we owe it to our patients to tend to their distress, there can be very serious consequences if ignored.

You don’t want to relearn this one again. You risk getting an angry patient and an invite to the wrong committee, doctor.